Notice of Claim

Title 59 requires you or your attorney file a formal notice of claim against a public entity and you have been seriously and permanently injured as a result of negligent and reckless conduct by a public entity. Meet with your attorney in their office immediately. There is a 90 day Notice of Claim statute and all appropriate entitles must be served properly. Notice of Claim Forward to: (Public entity) 1. Claimant ____________________________________________________________ Last Name, First, Middle _______________________ Date of Birth ____________________________________________________________ Street Address Mailing address if other then street _____________________________________________________________ City, State , Zip Code _____________________________________________________________ Social Security If notice and correspondence in connection with this claim are to be sent to a person other than claimant, complete item #2. 2. _____________________________________________________________ Name _____________________________________________________________ Mailing Address _______________________________ City, State, Zip Code Relationship to claimant: Attorney at law or ________________________________________ Explain relationship 3. The occurrence or accident which gave rise to this claim: a. __________________ Date ___________________ Time b. Describe the location or place of the accident of occurrence: ___________________________________________________________________ Municipality Exact place of the occurrence c. Describe how the accident or occurrence happened: If a diagram will assist your explanation, please use the reverse side of this form. ___________________________________________________________________ d. State the name and address of the state agency or agencies that you claim caused your damage: ___________________________________________________________________ State the name of state employees whom you claim were at fault, including any information that will assist in identifying and locating them. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ e. State the negligence or wrongful acts of the state agency and state employees which caused your damage. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ f. State the name and address of all witnesses to the accident or occurrence. ___________________________________________________________________ g. State the name of all police officers and police departments who investigated the accident. ___________________________________________________________________ 4. Damages a. Claim for damages: ( ) Personal Injury ( ) Property Damage ( ) or If other, explain in detail: ____________________________________________________________________________ ____________________________________________________________________________ b. If you claim personal injury, 1. Describe your injuries resulting from this accident or occurrence: ___________________________________________________________________ 2. Do you claim permanent disability resulting from this injury? ( ) Yes ( ) No If yes, describe the injuries believed to be permanent. 3. For each hospital, doctor, or other practitioner rendering treatment examination or diagnostic service state: Name of hospital or doctor or other facility : ____________________________________________________________________________ Address: ___________________________________________________________________ Dates if treatment or services: ___________________________________________________________________ Amount of charges to date: _____________________________________________________ Amount paid or payable by other sources such as insurance: ____________________________________________ 4. If you claim loss of wages or income as a result of the injury state: ______________________________________ Name of employer: Address of employer: ___________________________________________________________________ Your Occupation: Dates employed at this job: ___________________________________________________________________ Rate of Pay: Dates of absence from work: ___________________________________________________________________ Total of lost wages: If still out of work expected date of return: $_________________________________________ Note: If your claimed loss of income arises form self-employment or other than wages, attach a calculation showing the basis of your calculation of lost income. 5. Set forth any and all other losses or damages claimed by you: ________________________________________ c. If you claim property damage: ________________________________________________________________ 1. Describe the property damaged: ___________________________________________________________________ 2. The present time and location where item can be examined: __________________________________________ 3. Date property was acquired: ___________________________________________________________________ 4. Cost of the property: _________________________________________________ 5. Value of property at time of accident: ___________________________________________________________________ 6. Description of damage: ___________________________________________________________________ 7. Has the damage been repaired? If so by whom? ________________________________________________________ 8. Attach each estimate of repair costs to this form. ________________________________________________________ 9. Set forth in detail the loss claimed by you for property damage: _____________________________________________ d. Set forth in detail all other items of loss or damages claimed by you and the method by which you made the calculation. __________________________________________________________ 5. The amount of the claim: ______________________________________________ 6. Have you made a claim against anyone else for any of the losses claimed in this notice? ___________________________________________________________________ If yes set forth the names and addresses of all persons and insurance companies whom youve made claims against. ___________________________________________________________________ 7. Are any of the losses or expenses claimed herein covered by any policy of insurance? ___________________________________________________________________ 8. Have you received or agreed to receive any money from anyone for the damages claimed herein? If so set forth the details of this agreement. _________________________________________________ 9. The following items must be submitted with his notice: ___________________________________________________________________ (1) Copies of itemized bills for each medical expense and other losses and expenses claimed. ___________________________________________________________________ (2) Full copies of all appraisals and estimates of property damage claimed by you. ___________________________________________________________________ (3) Copies of all written reports of all expert witnesses and treating physicians. ___________________________________________________________________ (4) A letter from your employer verifying your lost wages. If self employed, a statement showing the calculation of your claimed lost income. __________________________________________________ I hereby certify that the foregoing statements made by me are true, that the attached statements, bills, reports and documents are the only ones known to me to be in existence at this time. I am aware that if any statement made herein is willfully false or fraudulent, that I am subject to punishment provided by law. Dated: ________________________________________ Disclaimer: This web site is purely a public resource of general New Jersey information (intended, but not promised or guaranteed to be correct, complete, or up-to-date). It is not intended be a source of legal advice, do not rely on information at this site or others in place of the advice of competent counsel. The Law Office of Kenneth Vercammen complies with the New Jersey Rules of Professional Conduct. This web site is not sponsored or associated with any particular linked entity unless specifically stated. The existence of any particular link is simply intended to imply potential interest to the reader, inclusion of a link should not be construed as an endorsement.